Hypertension is a condition of elevated blood pressure above the normal value (mentioned below), requiring antihypertensive therapy. The ultimate Public Health Goal of anti-hypertensive therapy is the reduction of cardiovascular & renal morbidity and mortality.
procedure of BP measurements and classification
How to measure BP
The device that is used to measure BP is called sphygmomanometer.
This uses an air-filled cuff wrapped around the upper arm which helps to obstruct the blood flow into the arm. By releasing the air pumped into the cuff in small and incremental quantities, eventually blood is permitted to flow back into the arm, at which point, the pressure inside the cuff is measured that is known as the systolic pressure which represents the pressure inside the arteries during contraction of the heart. When the heart relaxes between the beats the pressure drops and that is known as the diastolic pressure. Together, these two pressures are written as a ratio.
eg . 120/80 mmHg
Mean of 2 or more properly measured seated BP readings on each of two or more office visits using appropriate sized cuff.
-Search for Cardiovascular risk factors,
-Look for target organ damage i.e. Heart, brain, kidney, Peripheral arterial disease and Retinopathy.
-Try to find out the identifiable causes of hypertension : Secondary Hypertension
– Do a careful physical examination: Measurements of BP,BMI, Exam of Optic fundi, carotid, abdominal or femoral bruit, palpation of thyroid gland, thorough examination of heart and lungs, exam of abdomen for kidney enlargement , examination of lower limb for peripheral pulses and oedema.
(Hypertension as such has no specific clinical symptoms, So routine blood pressure measurement in OPD and Clinics for adult patients presenting with any other disease will help early diagnosis and management of hypertension.)
Haematocrit, urine analysis, blood glucose, serum potassium, calcium
Principle of Management :
In hypertension treatment, the expected Bp goal is < 140/90 mm Hg.
In patients of Diabetes or Renal disease with hypertension, the BP goal is < 130 / 80 mm Hg.
Start with Life style modification. If Goal BP is not reached go for Drug Treatment.
Non-drug Treatment (Life Style Modification)
Adaptation of healthy life style decreases BP, enhances antihypertensive drug efficacy and
decreases cardiovascular risk.
1. Weight reduction.
2. Eating food rich in Calcium, Potassium and reduced total fat and saturated fat.
3.Dietary Sodium restriction (6 gm of Sod. Chloride / day)
4. physical activity-Brisk Walking, Swimming and Jogging.
5. Moderation of alcohol consumption..
6. Cessation of Smoking.
Failure to achieve the goal by life style modification necessitates for initiation of pharmacopeiapy. Classes of drug used are outlined in the following table.
Commonly used antihypertensives
|CLASS OF DRUGS||NAME OF GRUGS||DOSE (Mg/DAY)||FREQUENCY|
|POTASSIUM SPARING DIURETIC||AMILORIDE||5-10||1-2|
|ANGIOTENSIN II ANTAGONIST|
|CALCIUM CHANNEL BLOCKER||AMLODIPINE||2.5-10||1|
|ALPHA 1 BLOCKER||PRAZOSIN||2-20||2-3|
|CENTRALLY ACTING DRUGS||CLONIDINE||0.1-0.8||2|
Principles of Pharmacotherapy
1.Start Thiazide Diuretics alone or in combination with one of other classes i.e. (ACE inhibitora, ARBs, Beta blockers, CCBs).
2. Add a 2nd drug of another group if single drug fails to achieve BP goal,
3. When BP is more than 20 / 10 mm Hg above the expected BP goal consider initiating therapy with 2 drugs.
4. Isolated systolic hypertension to be treated alike.
Fixed drug combinations have been recommended for use in hypertension :
Such Combinations are
1. ACE Inhibitors + CCB
2. ACE Inhibitors + Diuretics
3. ARB + Diuretics
4. Beta blockers + Diuretics
5. Beta blockers + CCB
6. Centrally acting drugs + Diuretics
The Algorithm for treatment of hypertension is as follows :
Anti hypertensive drug therapy recommended for use in Special situations
(A)Patients with IHD,
-Stable angina- Beta hlocker (preferably metoprolol), long acting CCB.
-Unstable angina and Myocardial infarction- Beta blocker (Metoprolol) + ACE inhibitors
-Postmyocardial infarction: ACE inhibitors, Beta blockers(Metoprolol), aldosterone antagonists
(B) Patients with Heart Failure
-Asymptomatic Ventricular dysfunction-ACEI, Beta blockers (preferably carvedilol)
-Symptomatic Ventricular dysfunction-ACEI, Beta blockers (Carvedilol), ARBs
(C) Diabetes with Hypertension
Combination of 2 or more drugs usually required. Thiazide diuretics,
Beta blockers, ACEI, ARBs & CCBs are beneficial. In Diabetic nephropathy, ACEI or ARB or Combination favourably affects the prognosis.
Methyldopa, Beta blockers and CCBs are to be used. ACEI & ARBs contraindicated.
(E) Women with Hypertension
Oral contraceptives increase BP. Hypertension not a contraindication for HRT.
Patiems should be made aware of possible unfavourable effects of different anti-hypertensives
and should inform the doctor if it occurs for chang over to another drug as and when required. Public health measures like diet & exercise are to, be emphasized by the treating physician.
1)Hypertensive emergncies like encephalopathy, myocardial infarction, unstable Angina, Pulmonary Oedema, Eclampsia, Stroke, Life threatening bleeding, Aortic dissection
require hospitalization & parenteral drug therapy & need referral to higher centres.
2) Resistant hypertension, which is the failure to achieve goal BP even after adhering to full doses of an appropriate 3 drug regimen, requires multi disciplinary consultation.